Chapter 2 - The Department of Health and Human Services
The greatness of a state is judged, in part, by how well it treats those least able to help themselves—children, the poor, the disabled and the elderly. A great state lifts up all of its citizens. It provides a hand up, not a hand out. In this area California is failing.
After two decades without significant change, California’s Health and Human Services Agency is a maze of overlapping and confusing programs. Often people do not know where to turn for help, or must negotiate a bureaucracy that wastes time and money and diminishes the dignity of those in need of assistance. Given the importance of these programs, these problems cannot be allowed to continue.
FINDINGS OF THE CALIFORNIA PERFORMANCE REVIEW
An analysis by the California Performance Review found three core problems with the current organization of the Health and Human Services Agency:
- Responsibility for Agency functions is scattered among numerous departments.
For example, businesses involved in health or community care have to contact different entities to become licensed. There are two different departments with responsibility for nutrition. Healthcare data is collected by multiple departments within the agency and stored in 60 different information systems. Within this fractured system, it is difficult for even the best-intentioned people to coordinate programs and activities. Many people within the current organizational structure are very good at what they do. But when responsibilities are dispersed among so many entities, these individuals are not able to leverage their talents to get the best results for the state in important areas like healthcare purchasing.
- There is significant duplication of common administrative and leadership functions.
Currently, separate eligibility determinations are made for the Food Stamps, Medi-Cal and CalWORKs programs. By consolidating eligibility determination it would be possible to reduce fraud and free up personnel who could be better deployed to deliver services to program recipients. 12 Form Follows Function.
- The current organizational structure is a remnant of the 1970s that does not reflect modern developments and best practices in health and human services.
Service delivery has undergone many changes in the last 30 years, including the switch from welfare being an entitlement to being a work transition program and the shift from Medi-Cal being a fee-for-service system to being administered through managed health plans. The collection of child support payments has become a major responsibility of the Agency. Unfortunately each of these changes has come with additional responsibilities that have just been tacked onto the Agency. As a result, the organization no longer reflects coherent priorities.
PROPOSED ORGANIZATIONAL IMPROVEMENTSTo solve these problems, the Health and Human Services Agency and its constituent departments should be reorganized into one integrated Department with centers focused around core functions. By doing this, the Department should be able to eliminate duplication and provide better service delivery in each Center.
The Secretary of the Health and Human Services Department should be responsible for coordinating all of the activities within the Department and providing the overall strategic leadership necessary to make California’s services the best in the nation. The Department should have six goals:
- To assure all Californians that the state’s public health systems will respond effectively and without delay in the event of any outbreak of disease or bioterrorism;
- To operate state facility and health professional licensing programs in a way that protects consumers and applies fair and rational licensing standards;
- To build an organization that better addresses the common linkages between mental health problems and substance abuse problems;
- To recognize the priority of providing both developmental and physical rehabilitation services to California’s disabled community;
- To provide effective assistance to any family that needs support from government on a temporary basis due to unforeseen circumstances; and
- To ensure that taxpayers get the best value possible for the health services purchased by the state.
To implement these strategic goals, the Health and Human Services Department should be composed of the following seven entities: the Office of the Secretary, the Center for Health Purchasing, the Center for Public Health, the Center for Behavioral Health, the Center for Services to the Disabled, the Center for Social Services and the Center for Finance and Supportive Services. This organizational framework is depicted in Exhibit 3. The management goals, proposed functions and transferred functions of the offices and centers of the proposed Department should be as follows:
Office of the Secretary
- Management Goal: The Secretary of Health and Human Services should serve as the policy level executive for all programs and as the primary point of accountability, reporting directly to the Governor, for the management of health and human services programs. The Office of the Secretary should bring together common functions that cut across the various health and human services programs operated within the Department.
- Proposed Functions: The Department should be strengthened with the following entities housed within the Secretary’s office: Office of Policy Analysis, Office of Health and Human Services Information, Chief Counsel, Office of Communications and Public Information, Office of Client Advocacy and Chief Fiscal Officer. These functions should be part of the Health and Human Services Department to provide cross-cutting policy and strategic direction for the operation of programs. The Office of the Secretary should also serve as the principal communication link between the Governor and the constituent units of the Department.
- Transferred Functions: The following functions should be transferred from multiple agencies within state government, and should be linked with similar functions in the various centers, as described below
- Authority for the health professions licensing boards that are currently in the Department of Consumer Affairs should be transferred from the State and Consumer Services Agency;
- Authority for the oversight of the programs administered by the Office of Environmental Health Hazards Assessment should be transferred from the California Environmental Protection Agency;
- Authority for the California Medical Assistance Commission should be transferred from the separately established commission to the Secretary of Health and Human Services; and
- Authority for the programs in the Department of Managed Health Care should be transferred from the Business, Transportation and Housing Agency.
Center for Health Purchasing
- Management Goal: This Center should maintain and improve the system of health care and insurance support for Californians. This Center should be committed to maximizing California’s purchasing power to achieve the “best price” and the “best service” in the delivery of health services.
- Proposed Functions: This Center should bring together health delivery and health purchasing programs into one organization. This consolidation should maximize the depth of experience in healthcare programs and should allow for the exchange of best practices among the healthcare and health insurance programs.
- Transferred Functions: The California Medical Assistance Commission should be abolished and its functions should be transferred to the Secretary of Health and Human Services. Functions that should be included in this Center are the existing health delivery and insurance programs in the current Health and Human Services Agency, including: Medi-Cal, California Children’s Services, Child Health and Disability Prevention, Genetically Handicapped Persons, County Medical Services and In-Home Support Services Programs. The Managed Risk Medical Insurance Program, the Access for Infants and Mothers Program and the Healthy Families Program, which are currently part of the Managed Risk Medical Insurance Board, should also be transferred to this center.
Center for Public Health
- Management Goal: The goal of this Center should be to prevent disease and premature death and to enhance the health and well-being of Californians. Leadership is needed to advise the Secretary of Health and Human Services and the people of California on current and emerging public health issues that have a major impact on the health of Californians.
- Proposed Functions: This Center should consolidate the core public health functions of the state into one organization that reports directly to the Secretary of Health and Human Services. This Center should include significant skill and experience in public health activities and should provide direction to the state and local public health activities and organizations. This Center should also include vital records, health manpower activities, communicable disease programs, health information and promotion programs and public health laboratories.
- Transferred Functions: The current public and environmental health programs from the Department of Health Services in the current Health and Human Services Agency should be the nucleus of this new public health effort. The functions of the Office of Environmental Health Hazards Assessment within the California Environmental Protection Agency should be transferred to this Center to strengthen the capacity to identify environmental health risks. Finally, the planning and manpower activities of the Office of Statewide Health Planning should be included as part of this Center.
Center for Quality Assurance
- Management Goal: The goal of this Center should be to provide licensing and oversight for businesses and consumers for health and human services. Consolidation should provide a consistent approach to the regulation of health care and human services in California.
- Proposed Functions: The Center for Quality Assurance should consolidate the licensing activities for health facilities, community care facilities and health professions into one organization.
- Transferred Functions: The current licensing functions from all departments in the current Health and Human Services Agency should be transferred into this Center. These activities include health facilities licensing from the Department of Health Services and community care licensing from the Department of Social Services. The authority of the health professions licensing boards currently part of the Department of Consumer Affairs should be transferred from the State and Consumer Services Agency. Authority for the programs in the Department of Managed Health Care should be transferred to this Center from the Business, Transportation and Housing Agency.
Center for Behavioral Health
- Management Goal: The goal of this Center should be to oversee the network of mental health and alcohol and drug treatment services provided in California. The main responsibility should be to oversee the application of state and federal laws in both county-operated programs and state-operated facilities.
- Proposed Functions: The Center for Behavioral Health should incorporate the treatment programs for mental illness and alcohol and drug dependency in one entity for consistency of administration and interface with county governments. In addition, the expertise for the management of the state’s mental health hospitals should be incorporated in this Center.
- Transferred Functions: This Center should incorporate the programs from the Department of Mental Health and the Department of Alcohol and Drug Abuse. The transfers should include the Community Mental Health and Alcohol and Drug Programs as well as the State Hospitals for the Mentally Ill.
Center for Services to the Disabled
- Management Goal: The goal of this Center should be to provide a high quality continuum of care to the developmentally and physically disabled. The Center should be the focal point for California’s special needs population.
- Proposed Functions: The Center for Services to the Disabled should consolidate all services to the developmentally disabled and the physically disabled into one organization.
- Transferred Functions: This Center should include services to the disabled from the Departments of Developmental Services and Rehabilitation. The specific programs in this area should include Regional Centers for the Developmentally Disabled, the Developmental Centers, the Work Activity Program, Independent Living Centers and Services to the Blind and Deaf.
Center for Social Services
- Management Goal: The goal of this Center should be to oversee the delivery of benefits and services that foster self-sufficiency, dignity and well-being in the lives of Californians.
- Proposed Functions: The Center for Social Services should consolidate the state’s income support programs including child support, community development programs and social services programs for children, families and aging individuals. This Center should also be responsible for the entire spectrum of support services for children and California’s aging population; it should also incorporate planning the continuum of care for both of these population groups.
- Transferred Functions: This Center should include the main programs of the Departments of Social Services, Aging, Community Services and Child Support Services. The programs in this Center should include: CalWORKs, Child Welfare Services, Child Support, Food Stamps, Supplemental Security Income, Services to the Aging and low-income energy grants.
Center for Finance and Supportive Services
- Management Goal: The goal of this Center should be to provide superior technical, financial and administrative support services through a shared services model.
- Proposed Functions: The Center for Finance and Supportive Services should consolidate the financial, technology, human resources and other support services for the centers in the Department and should provide technical support for county service providers.
- Transferred Functions: This Center should incorporate all administrative and technical support services that are within the entities that comprise the current Health and Human Services Agency. Specifically, technology, business services, personnel services and accounting services of the existing departments within the Agency should be consolidated into this Center.